Learning Disability Services Efficiency Project Interim position report

Delivering savings in learning disability services Contents

Background ........................................................................................................................................... 3 Emerging lessons .................................................................................................................................... 5 A. Promoting independence .................................................................................................................. 5 Developing the use of Personal Assistants in Barking and Dagenham ........................................... 5 The Progression Model in Darlington ............................................................................................... 6 The Progression model in Cumbria .................................................................................................... 7 Kent Pathways Service ...................................................................................................................... 7 B. Working collaboratively .................................................................................................................... 8 Increasing mobility in Barking and Dagenham .................................................................................. 8 Commissioning new services with the Clinical Commissioning Groups in Wiltshire ................. 8 Wiltshire Council working collaboratively with providers ............................................................... 9 C. Optimising the use of technology in service planning and delivery ............................................. 9 Using technology to support independent living in Darlington ..................................................... 9 D. Reducing costs .................................................................................................................................. 10 Alternative model of care in Kent ..................................................................................................... 10 Wiltshire focus on paying for the real cost of the care .................................................................. 11 Wiltshire focus on paying the right price to meet people’s needs ................................................. 11 Cumbria analysis of spend on residential care ................................................................................. 11 Conclusions .......................................................................................................................................... 12 The next steps ....................................................................................................................................... 12 Background

In 2011 the Local Government Association launched the Adult Social Care Efficiency (ASCE) Programme which aimed to share new, innovative and more efficient approaches to delivering adult social care. Fifty four councils took part in the three year programme, working on forty four projects. The LGA worked alongside these councils sharing emerging lessons and providing evidence of cashable savings across a range of transformational initiatives and approaches. The findings were reported in three publications, which can be found on the LGA website at http://www.local.gov.uk/childrenadultsfamilies.

The ASCE Final Report, published in July 2014, reported that councils were finding it particularly challenging to make savings in learning disability (LD) services due to an increase in demand for services (2-3% per annum) and increasing complexity of needs. In response the LGA launched the Learning Disability Services Efficiency (LDSE) Project to support councils in making the efficiency savings required. The project follows the model used for the ASCE programme where councils were given a grant to fund an external diagnostic of the service that is used to inform an efficiency plan. The plan aims to deliver the savings required in each area, while achieving the desired outcomes for service users. Council’s efficiency plans will be delivered to autumn 2016 and findings will be shared throughout the duration of the project for the benefit of the sector.

Five councils were selected to participate in the project; these are the London Borough of Barking and Dagenham, Cumbria County Council, Darlington Borough Council, Kent County Council and Wiltshire Council. The participating councils met for the first time in November 2014. All diagnostic reviews of the LD Service were completed early in 2015 and used to inform the areas of focus for each of the participating authorities. These are:

| Authority | Objectives | Projected savings | |----------------------------|---------------------------------------------------------------------------|----------------------------| | Barking and Dagenham | Transformation of day care opportunities in the Borough. | £670,000 | | Cumbria | a. To reduce the costs of residential care; | £5m over three years | | | b. Reduce costs through case reviews; | | | | c. Reducing day care placements and the associated transport costs; | | | | d. Working closely with the Clinical Commissioning Groups (£21.3 million of the budget is already pooled with the NHS). | | | Darlington | a. Wider use of assistive technology; | £1.16m | b. Further changes to day Opportunities; c. Increased access to employment; d. Better use of accommodation and support planning; e. Ensuring improved housing supply; f. Making stronger community connections; g. Building on Safe Communities programme; h. Housing and support for people with complex physical needs; i. Housing and support for people with complex behavioural needs; j. Housing options to support planning for individuals with learning disabilities.

| Kent | Meeting the needs of all 4,200 current service users. The three areas for consideration are: | |------|-----------------------------------------------------------------------------------------------| | | a. Alternative models of care; | | | b. Increased promotion and use of Shared Lives; | | | c. Pathways to independence. | | | £6.89m (target) to £13.32m (stretch target) |

| Wiltshire | The focus in Wiltshire has been in 4 areas: | |-----------|---------------------------------------------| | | a. Getting a stronger grip on both the activity data and the financial information; | | | b. Commissioning (jointly with the CCG and NHS) services which would assist people with challenging behaviours and assist in meeting the needs of those residents who had been placed in NHS Hospitals; | | | c. Review the costs of all residential and supported housing services; | | | d. Review care packages which were identified as being high. | | | Cashable and avoidable long term costs (to be reported in 2016) |

While it is too early in the delivery phase to evidence significant efficiency savings or impact for users, this report shares emerging lessons and good practice. The final report, published in the autumn 2016 will give evidence of efficiency savings and improved outcomes against the objectives determined by each area. Emerging lessons

Councils on the programme are adopting a range of innovative approaches to delivering person-centred care that improves outcomes for users and makes savings. All of the authorities are undertaking projects that are based on the principles of promoting independence; working collaboratively to develop person centred solutions; maximising the use of resources, including digital technology and reducing costs.

Below are some practical examples of the projects that the participating authorities are undertaking:

A. Promoting independence

Most of these interventions and approaches aim to promote independence of service users and build resilience in networks and communities to support people to live independently where possible.

Developing the use of Personal Assistants in Barking and Dagenham

Barking and Dagenham are in the process of transforming day care opportunities for people with learning disabilities. The council anticipate saving £670,000 from this work.

The focus is to ensure that each individual’s requirements are met according to their needs. Every person will have a support plan (whether they are eligible for formal services or not). Some people will receive minimum support and will be encouraged to access local community facilities, colleges and sports opportunities. Others will receive personal budgets to help meet their needs (including the employment of Personal Assistants).

The proposal is that one day centre (Maples) will close with the other council run centre (Heathlands) being retained. Three service users will transfer to Heathlands. There will be opportunities for some to use their personal budgets to access a privately run day centre which is located within the Borough (Osborne Partnership). Heathlands will have a reception service which can offer support to people who are not in receipt of a service but who may require some help or advice when required.

To support the move to wider use of Personal Assistants (PAs) the service has built on learning from the longer standing PA service that is run in the Borough to support older people. A post has been created to develop the use of PAs in the learning disability service and a special accreditation scheme has been developed to support the trainers of the PAs. This aims to ensure that those who work in the service have been offered proper training in some of the key aspects of the service, including understanding and assisting people with challenging behaviour; managing medication and recording medication; and other appropriate skills.

**The Progression Model in Darlington**

The principles used in Darlington are those of the “progression model” which is based on the view that each person with a learning disability has the potential to move to a higher level of functioning if they are given the appropriate care and support. For example there are people with challenging behaviours where these may be modified; people living in settings where they may be able to gain greater independence and those receiving services that may be able to gain their support from informal networks and community activities rather than formal care.

Life Stages 26+ Team has established a project team to take forward the work to improve the independence of adults with learning disabilities and at the same time find efficiencies. In 2014 a review of one of the in-house supported living provisions delivered savings of £32k as a result of reductions in the hourly rate staffing costs. A desktop assessment of options for the three in-house settings could deliver savings of £90,817 on current projections, based on the people remaining in these addresses with alternative provision from external providers. However closure of one or more of the settings may release further savings (both capital and revenue).

Savings have been achieved in Learning Disability Services in Darlington since 2010/11, despite the increase in the numbers of people accessing services, i.e. there has been an increase in the number of families of disabled children from 73 to 209 in 2013-14. A range of projects has seen a reduction in spend totalling £1,167,462 (including estimates for 2015-16).

In Darlington there is a single all-age service for children with a disability (managed within the Adult Care part of the Directorate) which is called the Life Stages Service. In view of these early successes further work is proposed to review cases across the Life Stages Service from both teams (0 to 25 and 26+). An initial desktop exercise will be undertaken to identify suitable cases from both teams. Deep-dive reviews will follow to challenge care packages and maximise reductions in costs whilst ensuring assessed need is supported and positive outcomes achieved.

In order to develop the progression model and to make new offers for adults with learning disability (extending the menu of choices available to them) new services have been developed. These include:

- Wider use of assistive technology;
- Further changes to day opportunities;
- Increased access to employment;
- Better use of accommodation and support planning;
- Ensuring improved housing supply; • Making stronger community connections; • Building on the Safe Communities programme; • Housing and support for people with complex physical needs.

The Progression model in Cumbria

Cumbria has also adopted the “progression model”. This approach looks at the best way of helping a person achieve their outcomes based on the person realising greater independence than before.

The councils spends £10.5 million on supported living accommodation and it has agreed to look at how this spend can be reduced through service users gaining greater independence. This service is currently out to tender. It is estimated that the new services could aim to achieve a reduction in spend of between £750,000 and £1,250,000 over a three year period.

Kent Pathways Service

Kent have established a pilot service to offer an enablement based approach to help adults with learning disabilities acquire greater independence. The Kent Pathways Service (KPS) offers sixteen options to promote independence, including options to develop skills in the home, using community resources, improving self-confidence, finding courses or work, looking at housing options and learning how to budget and pay bills, keeping well through diet and fitness and keeping safe. The programme is based on a 12 week offer but also involves working with the person to look at their longer term support needs.

An initial assessment of all adults with learning disabilities known to the council determined that 507 of these people were going to gain greater independence and were prioritised for the first phase of this service. The assessments in Kent show overall that 46% of service users who live in the community are very likely to be suitable for the programme and a further 21% may be suitable. The service is currently operating in three areas of Kent with 15 FTE staff working with the cohort of service users, although it is anticipated that fewer staff will be required in the future as the service becomes more established.

Case Study

Emma’s care agency requested an additional 4 hours per week to help manage her health and hygiene. She was referred to KPS to develop these skills and by increasing her independence, Emma no longer needs the additional support.

The service reports average savings of £26.08 per week and £30.20p per person per week of cost avoidance. If this figure is used for the 507 people who might benefit from the programme the possible annual saving is around £500,000 for the service. B. Working collaboratively

Reduced funding for social care, changes in legislation and increases in demand have strengthened the drive for health and social care partners to work collaboratively to meet the needs of all residents, including those with learning disabilities.

**Increasing mobility in Barking and Dagenham**

One of the hardest challenges facing services for adults with learning disabilities is how to reduce the costs of transport. Many service users rely on transport, often run by the council, to help them to access services. In collaboration with Transport for London a new travel training programme has been developed in Barking and Dagenham. A local garage has loaned a bus and crew to the service for one day a month. Volunteers, including off-duty police officers, act as passengers creating situations that the service users might encounter. Groups can spend a half day on the bus learning how to meet the challenges they might face on a journey before they try the public busses. In addition six former service users have been skilled up to act as instructors to support their colleagues in their travel training.

The council has also developed a volunteer driver scheme which can be used by service users to access appointments and for some leisure activities. There are currently 26 volunteer drivers, most of whom are retired, who work within this scheme.

The council has demonstrated that service users accessing these opportunities then need less council run transport, which could lead to significant savings. However in Barking and Dagenham, as in many places, the picture is more complex as the same transport fleet also are used for escorting children with special needs to school, so still need to be made available. Local discussions are taking place on how to better apportion the costs between these council services.

**Commissioning new services with the Clinical Commissioning Groups in Wiltshire**

Wiltshire Council and its Clinical Commissioning Groups have commissioned a range of new services to assist people who have learning disabilities who also have mental health problems and / or challenging behaviours. The aim is to both reduce expensive out of county placements (including eliminating the need for longer-term hospital placements) and to help people in the Council area to live more independent lives with better support.

A residential care home comprising five twin-bedded flats, designed for people with challenging behaviours will help people to better manage themselves and prepare for more independent living.

Wiltshire Intensive Support Service (WISS) will support people at home, a place of safety, or as an inpatient. It will be based within the joint health and care community team. (CTPLD) and work with mental health services, and other providers. The approach will be preventative to avoid hospital admissions, and to help to ensure people come out of hospital as quickly as possible if they do need to be admitted. It will help individuals to manage their behaviours and avoid escalations, it will upskill providers and families/carers where necessary, and in the long term the aim is to result in less interventions being necessary.

Alongside these new services there will be a training programme to assist all staff who work with people with complex needs and challenging behaviour which will focus on supporting people to avoid crises building up in their lives.

This service has just been launched and there are high expectations of not only improving outcomes for people but delivering savings to the service.

**Wiltshire Council working collaboratively with providers**

Wiltshire Council are building on the outcome focused commissioning work undertaken with older people to encourage and incentivise providers in the learning disability sector to meet needs in a way that maximises the independence of customers. This complements the council approach of providing supported living opportunities for adult service users, where possible, rather than residential care.

A new supported living provider accreditation scheme has been developed and implemented across Wiltshire. A new accreditation scheme for residential care is also being developed to reinforce the role of residential care in this overall approach, as well as to support the move to commissioning residential care by outcomes.

**C. Optimising the use of technology in service planning and delivery**

Councils recognise the opportunities offered by technology to target and deliver services better and to save money. Like many others, the Councils in this programme have used digital tools and approaches to improve access to services including tele-care, to promote independence and to plan and target resources effectively.

**Using technology to support independent living in Darlington**

Darlington Council have made a commitment to improve housing options for people with learning disabilities and complex behavioural needs, also to extend the use of assistive technology in supporting these people to live independently.

A housing matrix has been developed to gather information on the needs of all adults with learning disabilities in order better meet current needs and plan for future housing needs. The matrix has been populated with over 300 names and is used in reviews by social workers. Going forward the matrix will be used to plan for the housing requirements of younger individuals to enable appropriate accommodation to be built across the borough. This is particularly pertinent for young people who wish to live independently from their family when they reach adulthood. The matrix can also inform assistive technology requirements and ensure social workers explore all options for independent living.

Exploring the use of assistive technology has been identified as a priority for the council, partners (especially NHS) and individuals and their families with the aim of maintaining independence and increasing opportunities. Younger people with a learning disability are keen to explore the technology available to increase their independence especially around the use of Apps.

D. Reducing costs

To support new transformation plans, all of the councils in this programme still retain a programme to constantly review and reduce the costs of care.

Alternative model of care in Kent

The Alternative Model of Care programme (AMOC) has focussed on the longer term support needs of adults currently placed in residential care. In May 2015 there were 1253 people living in residential care funded by Kent County Council. A desk top review and risk assessment revealed that for 357 of these people there would be high risks associated with a planned move; 352 had a medium risk and for 249 people there was a low risk associated with a planned move. A further 33 people were identified as being suitable for the Shared Lives supported living programme.

The council focused initially on the latter group where it was known that people’s needs could be met in different settings. Managers were keen to ensure that the first group that would be supported in a move would be those who would benefit most with the lowest risk associated with delivering this.

In parallel to the assessment of need of individuals the commissioners undertook an assessment of the current market of supported living accommodation and discussed with providers and potential providers what future options and opportunities might be available. This led to a four pronged strategy:

- To make optimum use of current voids in the supported living services;
- To discuss with some providers the opportunity to de-register existing care homes for them to become based on the principles of supported living;
- To discuss with providers how some current properties might be adapted and changed to become supported living accommodation;
- To seek opportunities for new build schemes to be developed across the county. Managers in Kent are confident that, because they have taken time to identify which customers will benefit the most from the changes with least risk to themselves, and they have worked closely with providers to develop their strategy, there is a strong chance that the programme will deliver the outcomes identified and savings over the longer term. This does however mean that the majority of the savings may not be realised until 2017-18.

The Council are still finalising the cost benefits of this programme. Early calculations depend on whether all service users whose needs could be better met in supported living move or only those where it is thought that the move will result in lower costs. In this context the savings are considered to be in the range of £4.75 million and £8 million.

**Wiltshire focus on paying for the real cost of the care**

Wiltshire are looking to develop a model that helps them calculate the real cost of residential care. Detailed cost data collected by the Council reveals significant variations in the costs of residential provision to service users.

The Council will build on work that is taking place for older people in Wilshire. The findings will be used to inform discussions about future provision of residential care with providers.

**Wiltshire focus on paying the right price to meet people’s needs**

Like many other councils Wiltshire will continue to review the costs of care packages to ensure they are appropriate in relation to people’s needs. Initial work has revealed that over £262,000 that was allocated to people via direct payments went unspent. The resource allocation for these people is now being reviewed and adjusted accordingly. In addition, nearly £30,000 was saved by supporting a user to move from residential care to a supported living setting.

**Cumbria analysis of spend on residential care**

Cumbria Council spend £12.3m per annum on residential care for adults with learning disabilities. Of this, £7m was being spent with six providers. A detailed analysis of this £7m spend has revealed that costs range from £450 per week to £2000 for the high cost placements with these providers. Reviews of the needs of people living in the most costly of these residential homes (accounting for £2.3 million) has shown that their needs could be better met in different environments included supported housing. The Council anticipate savings of £350,000 if this can be achieved. If a similar pattern of findings came from all residential care placements there could be savings of up to £2 million in a three year period. Conclusions

Councils face significant challenges in balancing their budgets. This is most apparent in the Learning Disability Services where increased demand is putting these budgets under real pressure. All of the councils above have looked at ways of reducing their spend. The following approaches appear from this programme to be helpful in meeting needs while reducing costs:

- helping people live more independent lives with a reduced emphasis on formal and institutional care e.g. day care;
- reducing the use of residential care, while widening the use of cost effective housing options;
- working collaboratively with partners (Housing and Health) to find new interventions and new solutions;
- focusing on ensuring the cost of a service is linked to the needs of the customer;
- wider use of assistive technology in meeting the needs of adults with learning disabilities;
- focusing on community options and informal networks for those with lower needs;
- helping to manage people with challenging behaviours or those with higher needs.

The next steps

The five councils participating on the Learning Disability Services Efficiency project will continue over the duration of this project to transform services to meet the objectives set out in this report. The LGA will look to capture the learning from these areas and a final report will be published in the summer of 2016. The project aims to help all councils to reduce costs and make savings while maintaining outcomes for users in this key service area.

For more information please contact Amanda Whittaker-Brown Programme Manager Local Government Association

Local Government House Smith Square London SW1P 3HZ Email: amanda.whittaker-brown@local.gov.uk Telephone: 07879 640 814

Contact the Local Government Association Telephone: 020 7664 3000 Email: info@lga.gov.uk Website: www.local.gov.uk

© Local Government Association, October 2011